DR. ROMAN is a Fellow, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU School of Medicine, New York, N.Y.

Ashley S. Roman, MD, MPH

COMMITTEE ON PRACTICE BULLETINS-OBSTETRICS 

Practice Bulletin #203: Chronic Hypertension in Pregnancy. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e26-50. Full text of Practice Bulletin #203 is available to ACOG members at 

http://www.acog.org/Resources-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Chronic-Hypertension-Pregnancy

Chronic hypertension is present in 0.9-1.5% of pregnant women (1) and may result in significant maternal, fetal, and neonatal morbidity and mortality. The rate of maternal chronic hypertension increased by 67% from 2000 to 2009, with the largest increase (87%) among African American women. This increase is largely secondary to the obesity epidemic and increasing maternal age (1,2). The trend is expected to continue.

The purpose of this document is to clarify the criteria used to define and diagnose chronic hypertension before or during pregnancy, to review the effects of chronic hypertension on pregnancy and vice versa, and to appraise the available evidence for management options. The purpose of these revised best practice recommendations is to provide a rational approach to chronic hypertension in pregnancy based on new research and relevant pathophysiologic and pharmacologic considerations.

Taking a rational approach to hypertension in the pregnant patient

The new American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on chronic hypertension in pregnancy

 replaces the prior ACOG task force hypertension in pregnancy report from 2013, which covered the full range of hypertensive diseases in pregnancy in an extremely thorough way.  However, several factors prompted a needed update with a dedicated focus on chronic hypertension in pregnancy, particularly the new recommendations issued by the American College of Cardiology (ACC) and the American Heart Association (AHA) on the diagnosis and management of hypertensive disease in adults.

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Chronic hypertension in pregnancy is defined as any one of the following:

Hypertension diagnosed or present before pregnancy, whether or not a woman is on antihypertensive medication

Elevated blood pressure prior to 20 weeks of gestation on two occasions at least 4 hours apart. For the purposes of this diagnosis, a threshold of 140 mm Hg systolic or 90 mm Hg diastolic or both is used.

The basic core of these recommendations is unchanged from the ACOG task force report. However, it is unclear how to align the recent ACC/AHA guidelines

 with these pregnancy-related recommendations.  The ACC/AHA criteria for diagnosing hypertension in adults now classify blood pressure into four categories based on blood pressure results, with stage I hypertension (and recommendation for treatment) starting at a lower blood pressure threshold than we typically use for pregnancy, systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg.

While there is no consensus on how to apply the ACC/AHA recommendations to pregnancy, there does not appear to be benefit to initiating antihypertensive medication during pregnancy or low-dose aspirin for preeclampsia prevention for women who meet criteria for stage I hypertension during pregnancy based on a recent secondary analysis of a multicenter randomized controlled trial.

  However, data are limited on outcomes and preventative measures in women with stage I chronic hypertension.  Therefore, according to ACOG, it is reasonable to continue managing patients who met the criteria for a diagnosis of hypertension based on ACC/AHA recommendations (including stage I hypertension) prior to pregnancy as chronically hypertensive during pregnancy.

The bulletin also addresses another hot diagnosis: white coat hypertension.  Women with white coat hypertension are hypertensive during office visits but otherwise normotensive. They should be observed carefully during pregnancy as they are at increased risk of developing preeclampsia and gestational hypertension.

 Ambulatory blood pressure monitoring may be helpful when making decisions about starting antihypertensive medications in these patients.

Chronic hypertension carries risks to both mother and fetus during pregnancy, with severe and uncontrolled hypertension associated with the highest risks for both. For the mother, there is an increased risk of mortality, cerebrovascular accidents, pulmonary edema, and renal failure; however, the absolute risk of these complications remains low. Fetal risks include increased risk of stillbirth or perinatal death, fetal growth restriction, preterm birth (mostly ascribed to an increase in indicated preterm deliveries), and congenital anomalies, with the highest risk of these abnormalities correlating with presence of maternal end-organ damage.

The prepregnancy period remains the ideal time to initiate care-to look for end-organ damage, assess medications, look for signs of secondary hypertension (such as underlying renal, endocrine or vascular disease) and refer the patient for evaluation if needed, discuss the role of low-dose aspirin for preeclampsia prevention, improve blood pressure control prior to conception, and modify other risk factors that often are seen in conjunction with chronic hypertension, such as diabetes mellitus and obesity.

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Antepartum management is targeted toward blood pressure control, reducing risk of complications such as preeclampsia, identifying maternal and fetal complications early, and determining optimal timing of delivery.  At the first prenatal visit, baseline labs should be sent, including serum aspartate aminotransferase and alanine aminotransferase, serum creatinine, serum electrolytes, blood urea nitrogen, complete blood count, and spot urine protein/creatinine ratio or 24-hour urine for total protein and creatinine.  Electrocardiogram or echocardiogram should be ordered as appropriate.  Patients with either chronic hypertension or white coat hypertension should be advised to initiate low-dose aspirin (81 mg daily) between 12 and 28 weeks (optimally before 16 weeks) and continue it until delivery for prevention of preeclampsia.

For patients not already on an antihypertensive medication, antihypertensive therapy should be initiated when the systolic blood pressure is 160 mm Hg or more, diastolic 110 mm Hg, or both.  The target range is 120 to 160 mm Hg systolic and 80 to 110 mm Hg diastolic.  Lower targets may be desirable in women with signs of end-organ damage.

Which antihypertensives are best during pregnancy?  

Nifedipine and labetalol are recommended above other antihypertensive medications.  Methyldopa may be used but appears to be less effective than nifedipine or labetalol in achieving blood pressure control. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are generally not recommended due to the risks of fetal renal dysgenesis and calvarial hypoplasia. Other medications, such as conidine and prozosin, can be considered as second-line agents. Acute treatment of severely elevated blood pressure can be achieved using intravenous (IV) labetalol, IV hydralazine, and/or oral nifedipine.  The Practice Bulletin provides several different algorithms for achieving urgent blood pressure control.  Care should be taken to avoid overcorrection of blood pressure leading to hypotension, which can affect uterine perfusion.

Third-trimester ultrasound to assess fetal growth is advised in women with chronic hypertension. In terms of additional evaluation such as subsequent growth ultrasounds or fetal surveillance with nonstress testing or biophysical profiles, the Practice Bulletin does not make a solid recommendation due to limited data.

Timing of delivery depends on whether a patient is on antihypertensive medication and the degree of blood pressure control.  For all patients, delaying delivery later than 39 0/7 weeks should only be considered after a careful evaluation of the risks and benefits.

Chronic hypertension not on antihypertensive medication:  not earlier than 38 0/7 weeks

Chronic hypertension on antihypertensive medication with good control:  not earlier than 37 0/7 weeks

Chronic hypertension with superimposed preeclampsia without severe features:  at 37 0/7 weeks; if at a later gestational age than 37 0/7 weeks, then upon diagnosis.

Chronic hypertension with superimposed preeclampsia with severe features:  not later than

34 0/7 weeks; if at a later gestational age than 34 0/7 weeks, then upon diagnosis.

Immediate delivery after maternal stabilization is recommended if any of the following are present at any gestational age in women with superimposed preeclampsia:  uncontrollable severe hypertension, eclampsia, pulmonary edema, disseminated intravascular coagulation, new or worsening renal insufficiency, placental abruption, or abnormal fetal testing.

Fetal monitoring: Continuous fetal monitoring during labor is advised in women with chronic hypertension at higher risk of adverse outcomes (e.g., those who requre any blood pressure control or with other short-term or long-term sequelae).

Axial anesthesia: Axial anesthesia is safe even in the setting of severe hypertension. Unless contraindicated by thrombocytopenia, it should be used for cesarean delivery as general anesthesia may pose higher risks for women with severe hypertension.

A patient’s blood pressure should be evaluated in the first 1 to 2 weeks after delivery, either with an early outpatient office visit or with home blood pressure monitoring. Target blood pressure is systolic blood pressure of 150 mm Hg or less and diastolic blood pressure of 100 mm Hg or less. The patient can be maintained on the medication used in pregnancy or she can be transitioned back to her pre-pregnancy medication.  Medications such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are compatible with breastfeeding.  NSAID use appears to be safe in postpartum patients with chronic hypertension. Methyldopa should be avoided because it often can be associated with depression.

Diagnosing superimposed preeclampsia:  Up to 20% to 50% of women with chronic hypertension develop superimposed preeclampsia.  Diagnosing superimposed preeclampsia in patients with chronic hypertension can be a challenge.  It can be difficult to determine whether a surge in blood pressure represents worsening chronic hypertension or superimposed preeclampsia.  ACOG indicates that laboratory testing can be helpful in distinguishing between the two by evaluating platelet count, liver function tests, and uric acid levels.

Articles

Ashley S. Roman, MD, MPH, reviews some of the new updates discussed in ACOG Practice Bulletin #203: Chronic Hypertension in Pregnancy.